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England and Scotland in CVD risk mismatch

GPs in England and Wales will be taking decisions on statin use based on dramatically different risk evaluations from those in Scotland, a Pulse analysis can reveal.

The modified Framingham score recommended in draft NICE guidance last week calculates risks that can be as much as two-fold higher than those using the Assign score to be introduced in Scotland.

The findings will intensify concerns over diverging healthcare either side of the border, with differences in risk easily big enough to determine whether or not individuals will be eligible for treatment. Identical people may or may not receive statins depending on which side of the border they live.

Scotland's SIGN is currently validating the Assign risk tool, which takes into account deprivation and family history of cardiovascular disease, although not ethnicity.

But in England and Wales NICE has gone for a cruder method. It has chosen a standard Framingham assessment, with the recommendation that GPs should multiply by correction factors to allow for ethnicity and family history.

Dr Alan Begg, a GP in Montrose, Angus, and a member of the SIGN CHD guideline development steering group, said once Assign was validated it would lead to a divergence between the nations.

'That would be the natural consequence of using Assign if it's validated as a tool. Assign, in theory, should be a better predictor.'

A 60-year-old white male non-smoker with a blood pressure of 145/85mmHg and cholesterol levels of 5.2mmol/l total and 1.1mmol/l HDL will have a 17% 10-year CVD risk under Assign.

But his NICE-approved Framingham risk is 23%. If this man is South Asian his NICE risk increases further to 32% but under Assign it remains unchanged.

Dr John Pittard, a GP in Staines, Middlesex, and CHD lead at North Surrey PCT, said there should be no differences between countries.

'That's where risk assessment goes wrong. Particularly in terms of family history, that's quite arbitrary; there are no hard and fast rules about it.' He added: 'Multiplying by 1.4 or 1.5 suddenly means that you have an extra load of patients included in that bracket.'